Download Cancer of the Vulva

Cancer of the Vulva
Essentials of Diagnosis
• Typically occurs in postmenopausal women.
• Long history of vulvar irritation with pruritus,
local discomfort, and bloody discharge.
• Appearance of early lesions like that of chronic
vulvar dermatitis.
• Appearance of late lesions like that of a large
cauliflower, or a hard ulcerated area in the vulva.
• Biopsy necessary for diagnosis.
Types of Vulvar Cancer
• Squamous Cell Carcinoma- most common type
of tumor (85-90%) and most frequently involves
the anterior half of the vulva.
• Malignant Melanoma- second most common
vulvar cancer (5%)
• Carcinoma of Bartholin's Gland- most common
site for vulvar adenocarcinoma
• Basal Cell Carcinoma- arise almost exclusively in
the skin of the labia majora
Squamous Cell carcinoma
• 65% arises in labia majora and minora
• 25% percent in clitoris or perineum
• Appearance varies from a large, exophytic,
cauliflowerlike lesion to a small ulcer crater
superimposed on a dystrophic lesion of the
vulvar skin
• primary determinant of nodal metastases is
tumor size.
Malignant Melanoma
• Accounts for 5% of vulvar cancers
• most commonly arises in the labia minora and
clitoris
• superficial spread toward the urethra and vagina
• nonpigmented melanoma may closely resembles
squamous cell carcinoma
• darkly pigmented, raised lesion is a
characteristic finding
• All small pigmented lesions of the vulva are
suspect and should be removed by excision
biopsy with a 0.5- to 1-cm margin of normal skin
• large tumors, the diagnosis should be confirmed
by a biopsy
Carcinoma of Bartholin's Gland
• Rare (1%) but the most common site of vulvar
adenocarcinoma
• Most common type is squamous cell
metastasis
• Primarily lymphatics to the superficial inguinal
lymph nodes
• Direct extension to vagina, urethra and anus
Treatment
• TOC: wide local excision with inguinal lymph
node metastasis
• Stage I: ipsilateral lymphadenectomy
• Stage II and III: bilateral lymphadenectomy
• Late stage III and IV: radical vulvectomy,
lymphadenectomy and/or chemoradiation
Cancer of the Vagina
• Rare, approximately 3% of gynecologic cancers
• Squamuos cell(85%)>adenocarcinomas>
sarcomas>melanomas.
• Can be ulcerative or exophytic
Essentials of Diagnosis
• Asymptomatic: abnormal vaginal cytology.
• Early: painless bleeding from ulcerated tumor.
• Late: bleeding, pain, weight loss, swelling.
Endometrial Cancer
• 3rd most common gynecologic malignancy in the
Philippines
• Affects mostly peri/postmenopausal women
 RISK FACTORS:
 Estrogen replacement therapy
4-8x
 Menopause after 52 years
2.4x
 Obesity
3x-21 to 50lbs, 10x->50lbs
 Nulliparity
2-3x
 Diabetes
2.8x
 Feminizing ovarian tumors
 Polycystic ovarian syndrome
 Tamoxifen therapy for breast cancer >2 years
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Protective factors:
Ovulation
Progestin therapy
Combination oral contraceptives
Menopause prior to 49 years
Normal weight
Multiparity
• Etiology: unopposed estrogen exposure
• Clinical presentation:
Abnormal uterine bleeding (80)
Physical exam ussually unremarkable
Staging
FIGO Surgical Staging of Carcinoma of the Corpus Uteri
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Stage I
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Stage Ia G123 Tumor limited to endometrium
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Stage Ib G123 Invasion to less than one-half the myometrium
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Stage Ic G123 Invasion to more than one-half the myometrium
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Stage II
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Stage IIa G123 Endocervical glandular involvement only
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Stage IIb G123 Cervical stromal invasion
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Stage III
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Stage IIIa G123 Tumor invades serosa and/or adnexa, and/or positive peritoneal
cytology
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Stage IIIb G123 Vaginal metastases
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Stage IIIc G123 Metastases to pelvic and/or paraaortic lymph nodes
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Stage IV
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Stage IVa G123 Tumor invades bladder and/or bowel mucosa
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Stage IVb Distant metastases including intra-abdominal and/or inguinal lymph nodes
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Treatment
• Primary: surgery
bilateral salpingo-oophorectomy, peritoneal
washings for cytology, and removal of pelvic and
periaortic lymph nodes
• Adjuvant Chemotherapy: for advanced stages
Doxorubicin and cisplatin
Cancer of the Ovary
• Epithelial -65%
• Germ cell- 20-25%
• Sex cord-6%
• Etiology =frequent ovulatio n
• Risk factors=nullipairty, decreased fertility,
early and late menopause, ovulatory drugs
Clinical presentation
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Asymptomatic until late stage
Enlarging abdomen, abdominal mass
Urinary frequency, dysuria, GI complaints
Metastasis to the umbilicus is known as Sister
Mary Joseph Nodule
Epithelial Ovarian Cancer
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SEROUS - most common type
MUCINOUS
ENDOMETRIOID
CLEAR CELL
BRENNER
Management
• SURGERY- primary management
• CHEMOTHERAPY▫ Paclitaxel-Carboplatin 6 cycles every 3-4 weeks
• CA-125- elevated in 80% of px with ovarian Ca
-use to evaluate treatment
Germ cell Tumors
• 20-25% of ovarian cancers
• Arises from undifferentiated germ cells
Histologic Classification
• Dysgerminoma- most common malignant
GCT
• Teratoma- most common GCT
• Endodermal sinus tumor
• Embryonal carcinoma
• Polyembryoma
• Choriocarcinoma
• Mixed forms
Serum Tumor Markers for Germ Cell
tumor
hCG AFP LDH CA-125
Neoplasis
dysgerminoma
Mixed germ cell
tumor
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Embryonal
Carcinoma
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Endodermal sinus
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Clinical manifestation
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Tumors grow rapidly
Distention of the ovarian capsule
Hemorrhage
Pelvic pain
Pressure on rectum or bladder
Treatment
• Unilateral salpingo-oophorectomy
• Sensitive to chemotherapy- bleomycin,
etoposide, cisplatin (BEC)
• Dysgerminomas- radiation theraPY
• SURVIVAL RATE(5 year):
• Dysgerminomas-85%
• Immature teratomas-70 to 80%
• Endodermal sinus tumors- 60 to 70%
Sex Cord-Stromal Tumors
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Low-grade malignancies
Occur at any age
Usually unilateral and do not often recur
Functional tumors- produced hormones
Granulosa-theca cells: large amounts of
estrogens
• Sertoli-Leydig cells: testosterone and androgens
Granulosa-theca cell tumors
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Precocious puberty
Menstrual irregularities
Secondary ammenorrhea
Post-menopausal bleeding
Endometrial hyperplasia and/or endometrial
cancer
Sertoli-Leydig Cell tumors
• Virilization: breast atrophy, hirsutism, deepened
voice, acne, clitoromegaly and receding hairline
• Oligomenorrhea or amenorrhea
treatment
• Unilateral salpingo-oophorectomy
• Chemotherapy- not effective
5 year survival rate: 70-90%
Fallopian Tube Cancer
• Extremely rare: 0.5% of genital tract cancers
• 80-90% of FT malignancies are metastatic from
other sites (ovary, uterus, GIT
• Unknown etiology
• Hereditary association (BRCA1)
Clinical manifestation
• Hydrops tubae profluens: profuse watery
discharge, pelvic pain and pelvic mass
- Classic triad of fallopian Ca, only 15% of cases,
pathognomonic
Treatment
• TAHBSO, retriperitoneal lymph node sampling
• Carboplatin and paclitaxel- adjunct therapy